Colfax Health and Rehabilitation of Cascadia

Based on interview and record review, the facility failed to develop and implement a system to evaluate staff competencies in skills and techniques to ensure staff provided necessary care and responded to each resident's individualized needs for 3 of 11 sampled staff (Staff EE, U, and FF), reviewed for nursing services. This failure placed residents at risk of receiving care from inadequately trained and/or under-qualified care staff, unmet care needs, and diminished quality of life. Findings included . Review of the facility assessment reviewed 02/18/2025 showed the facility had an average daily census of 40 and provided 24-hour person-centered direct nursing care including restorative, therapy, and behavior services. The facility utilized temporary contracted staff as needed. Staff competencies were reviewed and determined annually to meet the needs of all residents. The facility additionally provided just in time training for conducting one-on-one training, read and signs, small groups or all staff in-services. Competencies could be verified by skills return demonstration or post…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to routinely complete annual staff performance reviews yearly as required and provide education based on the outcome of these reviews for 3 of 5 sampled nursing assistants (Staff I, L, and N), reviewed for performance reviews. This failure placed residents at risk of receiving care from inadequately trained and/or under-qualified care staff, and a diminished quality of life. Findings included . <Staff I> Review of Staff I's, Nursing Assistant (NA), personnel file showed they were hired on 07/16/2021. No documentation of a performance evaluation was found on file. <Staff N> Review of Staff N's, NA, personnel file showed they were hired on 02/01/2022. No documentation of a performance evaluation was found on file. <Staff L> Review of Staff L's, NA, personnel file showed they were hired on 04/04/2023. No documentation of a performance evaluation was found on file. In an interview on 06/13/2025 at 1:54 PM, Staff C, Resident Care Manager, stated they were unsure how often or who completed staff performance evaluations. In an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interviews, the facility failed to maintain an appropriate temperature in 1 of 1 medication storage rooms, ensure expired medications were removed from inventory and insulin vials were dated when opened for 1 of 2 medication carts, observed for medication storage. In addition, bottles of a liquid oral narcotic were not monitored for loss or diversion as required. This failure placed residents at risk of receiving less than the optimum dose of their medications, placed the facility at increased risk for potential controlled substance drug diversion and detracted from the facility's ability to promptly identify drug diversion. Findings included . Review of the 11/28/2017, last revised 10/15/2022, policy titled, Medication Management showed medications were discarded by the expiration date unless indicated by the pharmacy and/or manufacturer's instructions to discard sooner, labeled in accordance with facility requirements and State and Federal regulations and stored under proper conditions of sanitation, light, ventilation, segregation, and security. Narcotics…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure bedtime snacks were offered to 6 of 6 sampled residents (Resident 18, 26, 7, 11, 20 and 1), interviewed during Resident Council. This failure placed residents at risk for hunger and potential weight loss due to the gap between meals. Findings included . In an interview on 06/09/2025 at 11:18 AM, Resident 20 stated snacks were not being stocked. Resident 20 explained they would request a snack around 10:00 PM but staff would tell them the refrigerator was empty. During the Resident Council meeting on 06/10/2025 at 1:07 PM, Resident 18 stated they went without snacks at times. Resident 18 stated the dietary manager had been making snacks but was on vacation. The resident stated applesauce, peaches, and mixed fruit were offered but none were available in the evenings. Residents 26, 7, 11, and 1 all agreed with this information. In an interview on 06/14/2024 at 4:16 AM, Staff U, Registered Nurse, stated they ran out of snacks, but it was much better than it was two months ago. Staff U stated they did not have access to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure resident records were complete, accurate, readily accessible, and systematically organized for 3 of 4 sampled residents (Resident 28, 42, and 195), reviewed for transfer and discharge. This failure placed residents at risk of having an incomplete medical record, unmet care needs, and diminished quality of life. Findings included . Review of the facility policy titled, Discharge and Transfer revised April 2025 showed, a resident's medical record should reflect the basis for transfer and/or discharge and should be documented before or as close as possible to the actual time of transfer or discharge. <Resident 28> According to the 04/04/2025 admission assessment, Resident 28 admitted to the facility on [DATE] with diagnoses including medically complex conditions. Resident 28 had moderate cognitive impairment. Review of April 2025 through May 2025 nursing progress notes showed Resident 28 was transferred to the hospital three times, once on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure enhanced barrier precautions (EBP, use of personal protective equipment such as disposable gowns and gloves when providing high contact types of care for residents with drains, tubes, or colonized with antibiotic resistant bacteria) were implemented when indicated for 4 of 5 sampled residents (Residents 14, 195, 96, and 11) reveiwed, and that hand hygiene and EBP were implemented during 2 of 2 medication administration observations and 1 of 1 wound treatment observations. These failures created risk that antibiotic resistant bacteria were spread from resident to resident, and created potential risk of illness. Findings included . The Centers for Disease Control and Prevention (CDC) 07/12/2002 Implementation of Personal Protective Equipment (PPE, gloves, disposable gowns, eye protection or masks, for example) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms retrieved from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to repeatedly ensure nursing assistants received a minimum of 12 hours of in-service training per year, as required to include dementia management, abuse prevention, and caring for individuals with cognitive impairment for 2 of 5 sampled staff (Staff I and L), reviewed for nursing services. This failure placed residents at risk of receiving care from inadequately trained and/or under-qualified care staff, unmet care needs, and diminished quality of life. <Staff I> Review of Staff I's, Nursing Assistant (NA), personnel file showed they were hired on 07/16/2021. Review of Staff I's training records showed no documentation they received a minimum of 12 hours of in-service training per year as required to include dementia management, abuse prevention, and caring for individuals with cognitive impairment. <Staff L> Review of Staff L's, NA, personnel file showed they were hired on 04/04/2023. Review of Staff L's training records showed no documentation they received a minimum of 12 hours of in-service training per year as required…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to honor residents' choices regarding having the hoyer sling (a sling used for a full body mechanical lift transfer) left under them after being transferred into their wheelchairs, for 2 of 4 sampled residents (Residents 10 and 20), reviewed for choices. This failure placed residents at risk for not receiving resident specific care, not having their preferences honored, and a diminished quality of life. Findings included . <Resident 10> The 05/08/2025 assessment documented Resident 10 had diagnoses which included heart failure, diabetes, and chronic pain. Resident 10 was cognitively intact, able to make their needs known, and required total assistance with transfers. In an observation and interview on 06/09/2025 at 11:49 AM, Resident 10 was observed sitting in their wheelchair with a hoyer sling underneath them. The resident stated they did not like having the sling underneath them because it was uncomfortable and caused pain. A similar observation of Resident 10 with the hoyer sling underneath them was made on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to inform and provide written information regarding the right to formulate an advance directive (legal document that outlined wishes for medical care if a person was unable to make decisions for themselves) for 1 of 4 sampled residents (Resident 195), reviewed for advanced directives. This failure placed residents at risk of not being able to exercise their rights, not having their wishes honored, and a diminished quality of life. Findings included . Review of the facility policy titled, Advanced Directives/Health Care Decisions dated [DATE] showed, the facility would determine if a resident had executed an advanced directive or had given other instructions to indicate what care he or she desired in case of subsequent incapacity, upon admission. If the resident or their legal representative executed one or more advanced directives, copies would be obtained, incorporated, and maintained in the resident's medical record to be readily retrievable by any…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure residents requiring assistance with their activities of daily living (ADLs), were provided timely assistance according to their needs and preferences for 2 of 2 sampled residents (Residents 10 and 23), reviewed for ADLs. Specifically, Resident 10 was not provided bathing per their preference and Resident 23 was not provided nail care when indicated. This failure put residents at risk for a decreased quality of life. Findings included . <Resident 10> The 05/08/2025 admission assessment documented Resident 10 had diagnoses which included heart failure, diabetes, and chronic pain. The resident was cognitively intact and required substantial assistance for bathing. In an observation and interview on 06/09/2025 at 11:49 AM, Resident 10 was observed sitting in their wheelchair. The resident stated they did not get their bed baths very often. The 05/02/2025 ADL care plan documented Resident 10 was to be offered a bed bath if they could not tolerate a shower. The Nursing Assistant shower task documentation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement wound care orders for 1 of 3 sampled residents (Resident 195), reviewed for non-pressure related skin conditions. This failure placed residents at risk for wound complications, unidentified skin infections, and diminished quality of life. Findings included . According to the 05/29/2025 significant correction assessment, Resident 195 admitted to the facility on [DATE] with diagnoses including pelvis (bones at the base of the spine that make up the hips, buttocks and pubic area, between the abdomen and thighs) fractures and muscle weakness. The assessment further showed Resident 195 underwent a major surgical procedure during the prior inpatient hospital stay that required active skilled nursing care and had surgical wounds that required wound care. Resident 195 was cognitively intact and able to clearly verbalize their needs. Review of the 05/21/2025 hospital transfer orders showed Resident 195 had pelvis fractures that were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure behavioral health care services were provided for 2 of 3 sampled residents (Residents 28 and 18), reviewed for mood and behavior. Resident 28 was not referred for behavioral health support until after they voiced wanting to die, used a dinner knife to inflict injury to their left hand and made stabbing motions to their abdomen which required transport to the hospital, and additionally requested death with dignity (allowing terminally ill individuals to choose when and how they die, often with medical assistance). This failure placed residents at risk of experiencing further decline in their mental well-being, unmet care needs, and diminished quality of life. Findings included . Review of the facility policy titled, Behavioral Health Services revised April 2025 showed, the facility provided appropriate behavioral health services to residents identified through their individualized comprehensive assessment as needing support with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to timely act upon the pharmacy's monthly drug regimen reviews and/or pharmacist recommendations for identified irregularities for 2 of 5 sampled residents (Residents 6 and 11), reviewed for unnecessary medications. This failure placed residents at risk of inadequately monitored medications, potentially unidentified adverse consequences, and a diminished quality of life. Findings included . Review of the facility policy titled, Drug Regimen Review revised April 2025 showed, the facility pharmacy was to complete monthly drug regimen reviews to identify irregularities and clinically significant risks and/or actual or potential adverse consequences which may result from or be associated with medication use. The pharmacist was to review each resident's medical record once a month and provide a written report of any irregularities observed to the attending physician, medical director, and chief nursing officer. The policy showed the physician was to respond to irregularities within five business days. The attending physician either…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure residents were given their medications as ordered for 2 of 5 sampled residents (Residents 11 and 20) reviewed for medication management. This failure placed residents at risk of exacerbations of their chronic health conditions, and unintended consequences when doses of their medications were omitted. Findings included . <Resident 11> The 05/13/2025 five-day assessment documented Resident 11 had diagnoses including obstructive uropathy (a urinary tract disorder that occurred when urine flow was obstructed) and coronary artery disease (damage or disease in the heart's major blood vessels) and was cognitively intact. The 10/31/2024 care plan documented Resident 11 was incontinent of urine. Staff were instructed to monitor and report to the provider signs and symptoms of a urinary tract infection (UTI). The 04/11/2022 care plan documented Resident 11 received anticoagulant medication (blood thinning medication) related to a history of a blood clot to their lower extremities. Staff were instructed to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure documentation that facility staff were provided education regarding risks and benefits associated with the COVID-19 (a highly contagious viral illness that caused potential severe illness including possible death) vaccine, that staff were offered the vaccine, and that the COVID-19 vaccine status of staff was maintained for 2 of 2 sampled staff (Staff F and Q) reviewed. This failure placed staff at risk of not receiving vaccination against COVID-19 if desired, or information to determine the vaccine risks and benefits. Findings included . The facility policy COVID-19 Vaccination for Residents and Staff reviewed 06/02/2025 documented residents, their advocates and staff were educated regarding the benefits, risks and potential side effects associated with the COVID-19 vaccine. The COVID-19 vaccines are offered to residents and staff, and the administration, education, manufacturer and adverse reactions are documented. If residents or staff have previously received the vaccine, the facility requests documentation to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide a safe, sanitary, comfortable homelike environment for 3 of 5 sampled residents (Resident 6, 10 and 23 ), reviewed for environment. Specifically, the facility failed to ensure hazardous chemicals were securely stored in 1 housekeeping closet and 1 shower room accessible to Resident 6. In addition, the facility failed to ensure Resident 23's wheelchair was clean and in good repair, and Resident 10's drywall was repaired when needed. This failure placed residents at risk of potentially avoidable accidents and diminished quality of life. Findings included . <Unsecured Chemicals- Housekeeping Closet> In an observation on 06/09/2025 at 1:46 PM, the housekeeping storage closet on 200-hall was unlocked and able to be opened. The room contained chemicals that were harmful if swallowed or contacted the skin or eyes. No residents were wandering by the room. At 4:08 PM the door was locked. In an interview on 06/09/2025 at 4:10 PM, Staff Q, Registered Nurse, stated the housekeepers were the only people that had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to identify, evaluate and analyze risks, and implement safety interventions to reduce risks and hazards for 2 of 3 sampled residents (Resident 1 and 2), reviewed for accidents related to substance use disorder. This failure placed residents at risk of potentially avoidable accidents, and diminished quality of life. Findings included . <Resident 1> Review of Resident 1's electronic medical record showed that they admitted to the facility on [DATE] with diagnoses of schizophrenia (a mental health disorder characterized by distortions in thinking, perception, emotions, language, sense of self and behaviour) and psychoactive substance use disorder (uncontrolled use of a substance despite harmful consequences). Review of the Resident's facility care plan did not include interventions for substance use disorder. Further review did not show that the resident was identified by the facility as having this type of disorder, and no evaluation and analysis of risks,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record review, the facility failed to ensure that direct care staffing information was accurate upon submission to the Centers for Medicare and Medicaid Services (CMS) for Quarter 1 of 2024 (January 1, 2024 through March 31, 2024) reviewed for Payroll Based Journal (PBJ - mandatory reporting of staffing information based on payroll data) submission. This failure caused the CMS to have inaccurate data related to facility staffing levels and had the potneital to impact resident care and services. Review of the Certification and Survey Provider Enhanced Reports (CASPER) Payroll-Based Journal Staffing Data Report showed the facility reported data for Quarter 1, 2024 (Janaury 1, 2024 through March 31, 2024) at a level lower than required by mandated staffing levels. During an interview on 11/01/2024 at 2:45 PM, Staff A, Administrator, acknowledged the numbers submitted for Quarter 1 were not accurate due to not properly inputting data for agency staff. Staff A stated the home office submitted the data for the reports. Staff A was working with IT staff to resolve…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to provide care that maintained a resident's dignity for 1 of 3 residents (Resident 1) reviewed for quality of care. This failure placed the resident at risk for psychological harm, worsening skin problems and a diminished quality of life. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses which included stroke with left sided weakness. Review of Resident 1's comprehensive assessment, dated 09/18/2024, showed they had no cognitive impairments. Review of the resident's plan of care, dated 03/27/2024, showed the resident was at risk for skin problems due to fragile skin, history of pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin), incontinent of bowel and bladder, and dependent on staff for turning. Review of the resident's plan of care, dated 08/16/2024, showed the resident had potential/actual skin impairment due to a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview the facility failed to ensure food was labeled, dated and covered, and expired food was discarded on or before the expiration date for 1 of 1 kitchen reviewed. Additionally, the facility failed to ensure staff wore beard covering while preparing and serving food. These failures resulted in risk of food borne illness and diminished quality of life for all residents. In an observation of the facility kitchen on 07/08/2024 at 8:50 AM the following foods were noted in the refrigerators/freezers that were expired and/or past the use by date: -tortillas use by 6/30/2024 -macaroni salad use by 6/30/2024 -salsa use by 6/20/2024 -strawberry yogurt with expiration date of 6/1/2024 In addition, there were open packages of various berries that were not dated, uncovered celery in the refrigerator, and an open undated package of cooked eggs. During an observation of the resident nourishment freezer/refrigerator on 07/15/2024 at 5:00 AM multiple open food packages were observed that were not labeled with a resident name and/or the date opened or use by date. In…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure personal protective equipment (PPE) was implemented timely in accordance with the guidelines of the Centers for Disease Control (CDC) and the Local Health Department for the use of facial coverings after Resident 18 tested positive for COVID-19. This failure placed all residents and staff at risk for contracting COVID-19 (an acute respiratory illness caused by a virus, capable of producing severe symptoms and in some cases death, especially in older people and those with underlying health conditions). In addition, failure to ensure PPE was implemented for 2 of 4 sampled residents (Resident 13, 16) reviewed for Enhanced Barrier Precautions (EBP), failure to ensure resident 13's urinary catheter (a tube placed in the bladder to drain urine into a collection bag outside the body) was maintained in a sanitary manner, and failure to ensure hand hygiene was performed during the dining observation placed residents at risk for infection…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a safe, sanitary, homelike environment was maintained at the facility for 3 of 3 hallways reviewed. Failure to provide necessary maintenance and repairs in resident rooms and bathrooms, clean dirty carpets, flooring and wheelchairs and address odoriferous non transient odors throughout the building. placed residents at risk for accidents, injuries, unsanitary living conditions and diminished quality of care and life. Findings included . On 07/08/2024, during initial rounds of the building and throughout the survey period (07/08/2024 - 07/12/2024, 07/15/2024 -07/19/2024, and 07/22/2024) multiple resident rooms were observed with gouged walls, chipped paint, holes in the walls, nails on resident room walls with nothing hanging, un-sanded wall patches, cracked damaged blinds with missing slats, hazy windows, window screens clogged with dirt particles, damaged baseboards in resident rooms and bathrooms, and toilets and bathroom sinks…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 4 of 6 sample residents (28, 35, 40, 14) reviewed for Pre-admission Screening and Resident Review (PASARR, an assessment completed prior to admission into a skilled nursing facility to determine whether a resident with a diagnosis of a serious mental illness needed specialized mental health services) was completed prior to admission, accurately, and if indicated, a referral for a PASARR Level II (a more in-depth screening assessment) had been made. this faliure placed residents at risk on unmet care needs. Findings included <Resident 35> The 04/23/2024 quarterly assessment documented Resident 35 had diagnoses which included depression, psychotic disorder, a severe mental illness that caused abnormal thinking, delusions and hallucinations. Review of Resident 35's record showed a PASSAR was completed on 12/28/2023 prior to the resident's admission to the facility, but Section 1A documented the resident had no serious mental illness indicators and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to consistently provide bathing and/or grooming for 13 of 16 sampled residents (17, 18, 8, 1, 16, 13, 36, 39, 294, 33, 22, 14, 34) reviewed for activities of daily living. This failure placed the residents at risk for poor personal hygiene, diminished quality of life and unmet care needs. Findings included . <Resident 1> The 05/10/2024 quarterly assessment documented Resident 1 had bladder and bowel incontinence and needed assistance from nursing staff to complete activities of daily living (ADL) for bathing and shaving. On 07/08/2024 at 12:36 PM, Resident 1 was observed sitting in their wheelchair. The resident had long facial hair on the chin and upper lip. Review of the 06/18/2020 ADL care plan documented Resident 1 needed assistance for bathing, and preferred to have two showers a week. Instructions to nursing staff were added on 02/28/2023 to inform staff that Resident 1 needed assistance with shaving of facial hair and to reapproach if they refused. Additional observations of Resident 1 with facial hair on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure 2 of 3 nursing assistants (Staff V,W) met competency requirements defined under State Law, for license and certification. This failure placed residents at risk to receive care from incompetent and unlicensed staff. Findings included: Record review of employee files on 07/22/2024 documented Staff V was hired as a nursing assistant on 04/01/2024. Documentation in the file revealed that Staff V had a nursing assistant license that was pending. Staff V was observed in the facility on 07/09/2024, 07/11/2024 and 07/16/2024 providing care and services to the residents. Record review of employee files on 07/22/2024 documented Staff W was hired as a nursing assistant on 05/01/2024. Documentation in the file revealed that Staff W had a nursing assistant license that was pending. Staff W was observed in the facility on 07/08/2024, 07/09/2024, 07/11/2024, 07/12/2024, and 07/13/2024 providing care and services to the residents. In an interview on 07/22/2024 at 2:30 PM, Staff X, Administrator from a sister facility,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record review, the facility failed to ensure 5 of 8 sampled staff received mandated training on dementia and behavioral health. This failure placed the residents at risk for having unmet care needs and a diminished quality of life. Findings included . Review of competency training records for Staff W, Nursing Assistant, Staff BB, Cook, Staff JJ, Licensed Practical Nurse, Staff KK, Registered Nurse and Staff LL, Registered Nurse revealed they had not received any training on dementia and behaviors. During an interview on 07/22/2024 at 3:54 PM, Staff C, Clinical Resource Nurse, stated dementia and behavior training was important so that staff could meet the needs of the residents and should be offered to new employees and annually thereafter. Review of the 2024 Facility Assessment Tool provided by the facility documented training requirements included full time, part time and contracted staff. No Associated WAC

Based on observation, interview and record review, the facility failed to ensure catheter care was provided in a dignified manner for 1 of 2 sampled residents (Resident 13), reviewed for use and care of a urinary catheter (a flexible tube that passes through the urethra and into the bladder to drain urine). This failure placed the resident at risk for diminished quality of life. Findings included . Per review of the 05/27/2024 quarterly assessment, Resident 13 had diagnoses which included neurogenic bladder, (a condition in which one lacked bladder control due to a brain, spinal cord, or nerve problem), and utilized a urinary catheter. On 07/08/2024 at 09:03 AM, Resident 13 was observed asleep in their bed. The urine collection bag of their catheter was attached to the bed, not covered by a privacy bag. Additional observations of the collection bag without a privacy bag were observed on 07/08/2024 at 2:38 PM, 07/10/2024 at 4:52 PM, 07/11/2024 at 9:06 AM AND 11:31AM, 07/12/2024 at 9:11 AM, 07/15/2024 at 4:26 AM AND 7:33 AM, and 07/16/2024 at 10:41 AM, 11:48 AM, 12:36 PM and 1:50 PM.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 1 of 1 sampled resident (Resident 24) reviewed for accommodation of need, was provided a bariatric commode. This failure to ensure the resident received appropriate toileting equipment in their room placed them at risk for diminished independent functioning, and a loss of dignity and comfort. Findings included . Review of the resident's medical record showed the resident was admitted to the facility on [DATE] (age 39) with diagnoses to include obesity and a history of falls. The 07/03/2024 comprehensive assessment showed the resident required stand by to partial assist with activities of daily living and used a mechanical lift as needed for transfers. The assessment showed the resident was oriented and able to make their needs known and used a motorized wheelchair for mobility. During an interview on 07/08/2024 at 3:30pm, Resident 24 stated that they needed a large bedside commode because the bathroom in their room was too small…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to inform and provide written information concerning the right of their residents to formulate an advance directive for 2 of 3 sampled residents (Resident 17, 33) reviewed. This failure placed residents at risk of not being able to exercise their rights and not having their wishes honored. Findings included . <Resident 17> A review of the record documented Resident 17 admitted to the facility on [DATE]. A 04/29/2024 quarterly assessment documented Resident 17 had diagnoses which included a stroke, lung disease and depression. Resident 17's record did not contain documentation that they had been informed of their right to form an advance directive or if they had accepted assistance in forming one until 06/02/2024, more than four months after admission to the facility. <Resident 33> A review of the record documented Resident 33 admitted to the facility on [DATE]. A 07/25/24 quarterly assessment documented Resident 33 had diagnoses which included heart…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to ensure allegations of abuse were identified as such and reported to the State Survey Agency as required for 2 of 4 sampled residents (Resident 28, 40) reviewed for abuse. Failure to report an allegation of abuse by Resident 14 towards Resident 28, and failure to identify and report resident to resident altercations involving Resident 40 as potential abuse, placed the residents at risk for additional abuse, unmet care needs and diminished quality of life. Findings included . Review of the facility Abuse Prevention, Identification and Reported facility procedures revised 10/31/17 showed the facility procedures for reporting abuse: All staff members in all departments are required to immediately report any allegation of abuse to their direct supervisor and the State Survey Agency If their direct supervisor is not available report to the floor supervisor, CNO or CEO. You must speak with someone Facilities have two hours to notify state agencies and law enforcement if indicated so report to your supervisor immediately. Staff are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to thoroughly investigate allegations of abuse for 2 of 4 sampled residents (Resident 28, 40) reviewed for abuse. This failure placed residents at risk for not being adequately protected from additional episodes of abuse, unmet care needs and diminished quality of life. Findings included . Review of the facility Abuse Prevention, Identification & Reporting procedure dated 10/31/2017, directed staff to initiate investigations as soon as a report of abuse was received to rule out or identify abuse. Investigations would be completed within five days. On 07/08/24 at 9:37am. Resident 28 stated .A resident slapped me on the a I filed a police report . During an interview on 07/08/2024 at 10:22 AM, Resident 14 stated, I hit her on the butt. and identified Staff J, Maintenance/Transportation, witnessed it. The resident stated after the incident, they were directed by the police not to do that again, and by staff, not to inflame the situation with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure care plan interventions were implemented for 1 of 5 sampled residents (Resident 1) reviewed for care planning. Failure to ensure fall interventions for Resident 1 were followed. this failure placed the residents at risk for injury, and decreased quality of life. Findings included . <Resident 1> The 5/10/2024 quarterly assessment documented Resident 1 had diagnoses which included dementia, and was dependent on nursing staff for transferring to/from the wheelchair to bed. The assessment also documented the resident had weakness, was unsteady on their feet, and had a history of falling. On 07/08/2024 at 2:49 PM, Resident 1 was observed sleeping in bed in their room. A sign on the wall above the bed instructed staff, DO NOT leave resident alone in room. Transfer immediately or leave in common area. Thanks! Review of Resident 1's fall/safety care plan documented the resident was at high risk for falls and interventions were implemented on 11/21/2019. A revision of the care plan on 10/25/2023 informed staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and observations, during the medication cart review, the facility failed to provide timely administration of prepared medications according to accepted standards of clinical practice for 1 of 2 medication carts reviewed. This failure placed residents at risk of medication errors and decreased quality of life. According to the Institute for Safe Medication Practices, a delay between preparation and administration of a medication or the preparation of multiple medications for different clients is a contributing factor to medication errors and a risk to patient safety. (ISMP Canada Safety Bulletin - Volume 23 o Issue 12 o December 19, 2023, Pre-pouring Medications: A Risky Approach) Findings included: During an inspection of the 100-hall medication cart on 07/22/2024 at 4:28 PM with Staff R, Medication Technician, eight medication cups, each labeled with a different resident's name, and containing medications and were observed in the top drawer of the cart. In an interview on 07/22/2024 at 4:28 PM Staff R, said they prepared the 2:00pm medications but could not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to implement bowel management protocol when indicated for 1 of 2 sampled residents (Resident 26), reviewed for constipation. These failures placed residents at risk for complications, worsening conditions, and diminished quality of life. Findings included: Review of the undated facility policy titled, Bowel Protocol, instructed nursing staff to implement the bowel program if a resident did not have a bowel movement (BM) for 72 hours. The policy documented nursing staff was to administer Milk of Magnesia (MOM) or Miralax on the evening shift of 72 hours with no BM, a suppository on the following night shift, and an enema on the following day shift. Per the 05/24/2024 assessment, Resident 26 was cognitively intact, required maximum assistance for moving in bed, transfers, and toileting, and had diagnoses including multiple sclerosis (a disease that affects the brain and spinal cord and causes nerve damage and communication problems), hemiplegia (weakness or paralysis affecting one side of the body), and depression. Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure staff obtained accurate and timely weights 1 of 3 sampled residents (Resident 1) reviewed for nutrition. In addition, the facility failed to ensure the physician was notified of a change in a resident's condition (Resident 17) that impacted their nutrition. These failures placed the residents at risk for unrecognized, unplanned, significant weight loss, and nutritional complications. Findings included . <Resident 1> The 05/10/2024 quarterly assessment documented Resident 1 had diagnoses which included dementia, malnutrition, depression, vascular dementia, nutritional deficiency, mild protein-calorie malnutrition. Review of Resident 1's nutritional care plan documented the resident had an increased nutritional risk and interventions were implemented on 11/14/2019. A revision on 12/04/2023 instructed nursing staff to weigh the resident weekly. On 02/22/2024, a nutrition progress note by Staff RR documented the resident weighed 129.4 pounds which was a significant weight gain of 19.4 pounds (lbs.) in 16…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure that residents had current and complete oxygen orders and failed to ensure that oxygen equipment was maintained in a clean manner for 4 of 4 sampled residents (Resident 16, 39, 14, 27) reviewed for respiratory care. These failures placed the residents at risk for respiratory complications and infection. Findings included . A facility policy, dated 08/04/2023, titled Oxygen Therapy documented orders for oxygen were to be verified prior to initiating oxygen therapy. In addition, the policy documented to change disposable oxygen equipment routinely per manufacturer directives and PRN (as needed) soiling. <Resident 39> Per the 06/20/2024 quarterly assessment, Resident 39 had diagnoses which included COPD (a group of lung diseases that block airflow and make it difficult to breathe), chronic respiratory failure and needed oxygen due to those conditions. Review of the physician orders documented on 07/01/2024, the resident had been prescribed oxygen to maintain oxygen saturations between 88 and 98 percent,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to provide person-centered pain management for 1 of 2 sampled resident (Resident 294). Resident 294 was not offered pain medication and non-pharmacological pain interventions, non-pharmacological interventions were not documented when they were administered and failed to notify the physician and request additional pain management interventions. These failures placed the resident at risk for increased pain and decreased quality of life. Findings included . Per the 06/25/2024 comprehensive assessment, Resident 294 had diagnoses which included a stroke, sacral ulcer (pressure sore near the lower back and spine) and quadriplegia (paralysis of the arms and legs) due to a motor vehicle accident. In addition, the assessment showed the resident was cognitively intact to make decisions regarding their care, exhibited verbal and physical aggressive behaviors and was dependent for all cares. Review of the June 2024 and July 2024 Medication Administration Record (MAR) showed physician orders to administer scheduled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, observation and record review, the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 of 3 residents (Resident 28) Failure to assist with discharge planning placed resident at risk for a decreased quality of life. Findings included: The resident admitted to the facility in May 2023. Review of the Minimum Data Set (MDS) assessment, dated 04/30/2024, revealed they did not have any cognitive impairment. The MDS indicated resident 28 had behaviors, the facility coded her behaviors did not significantly intrude on the privacy or activity of others, and that the behaviors did not significantly disrupt care or living environment. The MDS indicated she was independent with Activities of Daily Living (ADL's) to include, bed mobility, transfers, locomotion on/off unit, dressing, toilet use and personal hygiene. On 07/08/2024 at 2:42pm, Resident 28 stated she would like to be living somewhere else. When asked if she was getting assistance with finding alternate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure expired medications were disposed of timely, in accordance with currently accepted professional standards, in 1 of 1 medication storage rooms. The facility further failed to ensure narcotics were locked in a permanently affixed narcotic container in 1 of 1 medication storage room refrigerators. These failures placed residents at risk for receiving compromised or ineffective medication and placed the facility at risk for potential diversion or misappropriation of narcotic medications. Findings included . During an observation of the medication storage room on 07/15/2024 at 7:45 AM with Staff, AA, Registered Nurse (RN), the refrigerator contained influenza vaccines that had expired on 06/30/2024 and Tuberculin (used to check for tuberculosis) that was opened on 04/27/2024 and not discarded after 30 days as required. The medication refrigerator held a white box, which was used to store narcotic medication, and was not locked as required. During an interview on 07/22/2024 at 5:49 PM, Staff B, Director of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record review the facility failed to implement their respiratory protection program for fit testing procedures which included a medical evaluation, fit testing (a 20 to 30 minute procedure to ensure a proper seal between the respirator face piece and the staff member's face) and training on the use and wearing of the respirator mask) of the N95 respirator mask (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) for staff. The facility had not implemented the respiratory protection program for 4 of 5 staff (Staff A, B, C, D) every year within 12 months of the date of the last fit test. A COVID-19 (infectious disease by a new virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) outbreak began in the facility on 06/17/2024 with 10 residents and 12 staff testing positive for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to perform thorough assessments, evaluate for changes in condition and notify the physician following significant changes in condition for 1 of 3 residents (Resident 1) reviewed for assessments. This failed practice placed Resident 1 at risk for a delay in medical treatment and medical complications. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses which included stroke with right sided weakness, aphasia (language disorder that affected a person's ability to communicate), diabetes and heart disease. Review of Resident 1's comprehensive assessment, dated 03/22/2024, showed they had severe cognitive impairment and was independent with all activities of daily living. Review of physician's orders showed Eliquis (blood thinner medication) was ordered on 11/14/2023 to treat Resident 1's heart disease. Review of Resident 1's April 2024 Treatment Administration…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure timely physician visits were completed for 1 of 3 residents (Resident 1) reviewed for physician visits. This failure placed residents at risk of being denied face-to-face contact with a physician, comprehensive reviews and physician assessments of their health and well-being. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses which included stroke with right sided weakness, diabetes and heart disease. Review of Resident 1's comprehensive assessment, dated 03/22/2024, showed severe cognitive impairment. Review of physician's assessments showed the last visit by a physician was on 11/22/2023 (slightly over five months ago). On 05/03/2024 at 2:06 PM, Staff A, Medical Director, stated they took over as the facility Medical Director in December 2023 as the previous Medical Director retired that month. Staff A stated they thought Resident 1 was being seen by an outside…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to timely complete, thoroughly investigate and provide prompt resolutions for concerns brought forth to staff by residents and/or their representatives individually or during the Resident Council Meeting for March 2024 for 3 of 8 residents (Residents 2, 4 and 5) reviewed for grievances. There was no documentation staff informed residents of the corrective actions taken, if any, to address their reported concerns. These failures prevented the facility from ensuring residents' concerns were timely and effectively addressed, care trends were identified and placed all residents at risk of frustration, diminished self worth, unmet care needs and diminished quality of life. Findings included . Review of the 03/21/2024 Resident Council Minutes showed 16 residents attended the meeting. Residents voiced concerns that call lights were not being answered promptly by staff. The meeting was facilitated by Staff H, Activities Director (AD). <Resident 5>…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review the facility failed to provide assistance with activities of daily living relative to bathing for 2 of 7 residents (Residents 1 and 2) dependent on staff for bathing. This failed practice placed residents at risk for embarrassment, poor hygiene, unmet care needs and a diminished quality of life. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE]. Review of the comprehensive assessment, dated 03/29/2024, showed they had no cognitive impairments. Review of the 03/27/2024 plan of care showed Resident 1 required partial and/or moderate assistance by staff with bathing. On 04/05/2024 at 10:30 AM, Resident 1 stated they had not been bathed by staff since they were admitted to the facility (10 days prior). They stated they were very frustrated and were not even on a bathing schedule yet. On 04/05/2024 at 2:30 PM, Staff A, Director of Nursing, stated they were unable to locate any bathing records on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure staff reported allegations of abuse immediately to administrative staff, and as mandatory reporters to the State Survey Agency as required, which caused a delay in investigating alleged staff to resident abuse for 1 of 1 resident (Resident 1) reviewed for abuse reporting. This failure placed residents at risk for lack of protection from being abused and a diminished quality of life. Findings included . Record review of the facility's policy titled, Abuse Prevention, Identification, & Reporting, revised on 10/31/2017, showed all staff members in all departments are required to immediately report any allegation of abuse to their direct supervisor. Abuse is not determined by the staff member to whom the allegation was made. If their direct supervisor is not available, report to the floor supervisor, Chief Nursing Officer (CNO) or Chief Executive Officer (CEO). You must speak with someone, a written note left for a supervisor is not immediate .call.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to maintain a sanitary kitchen environment and to prepare, distribute and serve food in accordance with professional standards for food services. Failure to ensure food was stored and served in a sanitary manner as well as maintaining a sanitary kitchen environment placed all residents at risk for cross-contamination (physical spread of germs), food borne illnesses and a diminished quality of life. Findings included . Record review of the facility's policy titled, Food and Supply Storage, dated 11/28/2017, showed all food, non-food items, and supplies used in food preparation shall be stored in such a manner as to maintain safety and sanitation of the food or supply for human consumption as set forth in the Federal Drug Administration Food Code, state regulations, and city/county health codes. For food products that are opened and not completely used or prepared at facility and stored, the product should be labeled as to its contents and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record review the facility failed to prepare palatable (acceptable/appetizing) meals for 6 of 9 residents (Resident 2, 3, 4, 5, 6, 7) reviewed for food service. This failure placed the residents at risk for a diminished dining experience, dissatisfaction with food served and a potential for less than adequate nutritional intake leading to weight loss. Findings included . <Resident 2> Review of Resident 2's comprehensive assessment, dated 07/19/2023, showed they had no cognitive impairments (thinking, reasonng, remembering). During an interview with Resident 2 on 10/12/2023 at 2:30 PM, they stated on 10/10/2023 they had burnt toast and a burned fried egg, which was not even recognizable. On 10/11/2023 they received the first food tray out of the food cart (eats in room) and the breakfast meal was so cold they would not eat it. They stated the dinner meal on 10/10/2023 was a cold hamburger patty. The slice of cheese was not on the patty and the hamburger was stuck to the plate. On 10/01/2023 Resident 2 received a fried egg on their plate for breakfast that was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide required transfer notices to 4 of 4 sample residents (6, 8, 18, 30), reviewed for hospitalization. The facility failed to provide the resident and/or their representative a written notice at the time the resident was transferred to the hospital, and failed to send a copy of the notice to the Ombudsman as required. Findings included . Review of the facility policy titled, Transfer & Discharge with a revision date of 10/15/2022, showed, .1. For exceptions to the 30-day notice rule, notice is given as soon as practicable. m. Sends a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. 4. At the time of transfer/ discharge, the resident and a family member or legal representative are given written notice. Resident 6 Review of Resident 6's electronic medical record showed they were originally admitted to the facility in April 2021, and readmitted on [DATE]. Review of the electronic progress notes showed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide required bed-hold notices for 4 of 4 sample residents (6, 8, 18, 30), reviewed for hospitalization. The facility failed to provide a written copy of a bed-hold notice prior to or within 24-hours of transfer to the hospital. This failure created the potential for residents and responsible parties to not have the information needed to safeguard their return to the facility. Findings included . Review of the facility policy titled, Transfer & Discharge with a revision date of 10/15/2022, showed, .4. At the time of transfer/discharge, the resident and family member or legal representative are given a written notice of the bed-hold policy that specifies the duration of the bed-hold and readmission criteria after the bed-hold period ends. Review of the facility's policy titled Bed-Hold Readmission, released 11/28/2017, showed, The facility issues two notices related to bed-hold policies . b. The second notice is provided to the resident, and if…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure one staff member disinfected a multi-use glucometer (a small, portable machine used to measure how much glucose - a type of sugar - is in the blood), per manufacturer's instructions between uses for one of three sample residents (11), observed receiving finger stick blood glucose tests. This failure had the potential to spread bloodborne pathogens during finger-stick blood glucose checks between three residents who shared the glucometer. Findings included . Review of the facility policy titled, Work Practices- Cleaning, dated 01/01/2018 showed, . 2. Resident care items are cleaned, disinfected or sterilized according to manufacturer's instructions. b. Multiple use resident care items are properly cleaned/disinfected between each resident use (. germicidal agent recommended by manufacturer's instructions). Resident care items may include, but is not limited to: 1) Glucometer. Review of the undated manufacturing instructions for the blood glucose monitoring system showed on page 44, Cleaning and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.